Child Care Reimbursement Form
Please also provide a copy of receipts for child care, a photo taken of the receipt will also be acceptable. Send photo or copy of receipt to TSLHR@thespringsliving.com
Sign in to Google to save your progress. Learn more
FIRST NAME *
LAST NAME *
EMAIL ADDRESS
Which Community do you work at? *
What is the name of your Child Care Facility closing due to COVID-19? *
What is the address of your Child Care Facility closing due to COVID-19?
What is the age of the dependent(s) you are applying for reimbursement for services rendered?
What is the name of your new Child Care Facility?
What is the address of your new Child Care Facility?
Please check the box(s) for the service day(s) that you are requesting for Child Care Reimbursement.
Column 1
Friday, May 1
Saturday, May 2
Sunday, May 3
Monday, May 4
Tuesday, May 5
Wednesday, May 6
Thursday, May 7
Friday, May 8
Saturday, May 9
Sunday, May 10
Monday, May 11
Tuesday, May 12
Wednesday, May 13
Thursday, May 14
Friday, May 15
Saturday, 16
Sunday, May 17
Monday, May 18
Tuesday, May 19
Wednesday, May 20
Thursday, May 21
Friday, May 22
Saturday, May 23
Sunday, May 24
Monday, May 25
Tuesday, May 26
Wednesday, May 27
Thursday, May 28
Friday, May 29
Saturday, May 30
Sunday, May 31
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy